The likelihood of a child born in Asia and the
Pacific surviving beyond his or her fifth
birthday has improved dramatically over the
past two decades. However, wide disparities
still exist at the country level, and child
mortality rates remain stubbornly high in
a large number of countries in the region.

The under-five mortality rate (U5MR) in Asia
and the Pacific was reduced from 86 per 1,000
live births in 1990 to 49 per 1,000 in 2009.
While this is an impressive improvement, many
countries are unlikely to achieve Millennium
Development Goal 4 (MDG-4), which targets
a two-thirds reduction in U5MR between 1990
and 2015.

The infant mortality rate (IMR – an
approximation of the number of deaths per 1,000
children born alive who die within their first
year) was reduced by over one third, from its
1990 level of 63 deaths per 1,000 live births to
38 in 2009, slightly better than the world average
of 43. The Asia-Pacific region thus falls between
Africa, with an IMR of roughly the double, and
Latin America and the Caribbean, with an IMR
of roughly half that of Asia and the Pacific.

The most disturbing IMR and U5MR in the
Asia-Pacific region occured in South and South-
West Asia at 52 and 69, respectively, in 2009.
Although considerately above the Asia-Pacific
average, the rates are still lower than the average
rates of Africa; and they represent remarkable
improvements of 40% and 43% respectively
since 1990.

At the other end of the spectrum, East and
North-East Asia registered the lowest IMR, at 16,
in the region and the lowest U5MR, at 18, in
2009. North and Central Asia had an IMR of
22 and U5MR of 24. Notably, both subregions
have reduced their rates by more than or almost
half since 1990.

Not surprisingly, the low and lower middleincome
countries have higher IMR and U5MR,
in general, illustrating how death rates among
infants and children are critically related to
a country’s economic progress.

Variations in IMR and U5MR are seen across
subregions as well as among countries within
subregions. The average IMR for the entire
Asia-Pacific region has been reduced by 39%
from its 1990 level. Whereas East and North-East
Asia shows the largest reduction at 54%, the
Pacific subregion has reduced its rates only by
21%. Although the Pacific has seen only
moderate improvements in IMR and U5MR
during the past two decades, the Pacific region
had the lowest IMR in 1990 and is still much
below the regional average as of 2009. However,
there are some alarming cases in the Pacific, such
as Nauru which experienced a threefold increase
in IMR between 1990 and 2009. In the Asia-
Pacific region, Afghanistan is an outlier with the
highest IMR in 2009, at 134; although this is an
alarmingly high rate, it still represents a reduction
of 20% from the 1990 level of 167.

Notably, a few LDC and LLDC countries have
already achieved the MDG-4 target in reducing
their U5MR by two-thirds; specifically, Mongolia
(101 to 29), Timor-Leste (184 to 56), and the
Maldives (113 to 13). One reason behind such
impressive gains is that those countries had very
high rates in 1990 that benefitted from successful
delivery of key child-survival interventions.
The extraordinary success of Maldives deserves
mention – it is the only country in Asia and the
Pacific to have reduced child mortality by nearly
90%. Although some countries are likely to
achieve the MDG-4 target, many still lag far
behind, particularly in North and Central Asia
and in the Pacific.

Across Asia and the Pacific, U5MR has been
reduced by a remarkable 43%. However,
disparities exist at the subregional and country
levels. Asian subregions registered a 43-58%
reduction (depending on the subregion), while
the Pacific subregion reduced its rate by only
22%. The U5MR in East and North-East
Asia countries ranged from 3 (Japan) to 33
(Democratic People’s Republic of Korea) in 2009.

Overall, the lowest U5MR levels (below 10) in
the region occur in Australia, Brunei Darussalam,
Japan, Malaysia, New Zealand, the Republic of
Korea, and Singapore. The highest U5MR
(likewise the highest IMR) is found in
Afghanistan – a shocking 199 per 1,000 live
births. This statistic stands in contrast to the three
next highest, which are an order of magnitude below that of Afghanistan: Cambodia (88),
Pakistan (87) and Bhutan (79).

Child health, survival and development are
causally and directly linked to nutritional status.
The evidence to date suggests that reducing
malnutrition levels will reduce child mortality.
That relationship is explained by a complex set
of variables, including underlying factors related
to poverty, including food security, care of
children, health services and environmental
conditions. The prevalence of underweight
children under 5 years of age is a key measure of
malnutrition, and is one of the nine indicators
used in monitoring progress towards the
MDG-1 target of eradicating extreme poverty
and hunger.

Unfortunately, data on the prevalence of
underweight children is not available at regular
time intervals for most Asia-Pacific countries.
Conclusions based on this data are hence difficult
to make.

In Asia and the Pacific, progress has been limited
in reducing the prevalence of underweight
children. However, based on available data,
10 countries have seen a 30% or more decrease
in the proportion of underweight children
(Bangladesh, China, Islamic Republic of Iran,
Kazakhstan, Malaysia, Mongolia, Thailand,
Turkey, Uzbekistan and Viet Nam).

South and South-West Asia has the most
countries with a high prevalence of underweight
children. Four of ten countries in the subregion
have a prevalence of underweight children of
40% or more, Afghanistan (40% in 2004),
Bangladesh (46% in 2007), India (48% in 2005)
and Nepal (45% in 2006). Outside South and
South-West Asia, only one country has a
prevalence of underweight children of more than
40%: Timor-Leste (49% in 2007).

Keep in mind, that such estimates must be
interpreted with caution, owing to the limitations
of recent data, particularly at the country level.
Nonetheless, the seriousness of the issues is
clear. Data aggregated by economic grouping
demonstrate an obvious pattern of higher-income
countries showing better progress and lower levels
than countries in lower-income groupings.

Figure I.12 – Children under 5 underweight,
Asia and the Pacific, earliest and latest

Immunization

In the struggle to improve child mortality rates,
a powerful preventive measure is availability of,
and access to, effective immunizations. Vaccinepreventable
childhood diseases include measles,
polio, hepatitis B, diphtheria, pertussis, and
tetanus. Vaccines for diphtheria, pertussis
and tetanus are administered together in a
combination called DPT; the third and final dose
of this vaccine, DPT3, is considered the best
population-based measure of children reached
with routine childhood immunizations. In Asia
and the Pacific, DPT3 coverage has been high for the past decade; the coverage in 2009 was 83%
(when the global average was 82%), up from
79% in 1990. The best performing subregions
are East and North-East Asia (97%) and North
and Central Asia (96%), followed closely by
South-East Asia (88%) where the rate has
improved remarkably from 75% in 1990.

The most stubborn DPT3 immunization rates
are in South and South-West Asia; these are low
as a direct consequence of the decline in DPT3
immunization coverage in India, which currently
stands at 66%, down from 70% in 1990. All
other countries in the subregion have seen an
increase in DPT3 immunization.

Other low performers in the Asia-Pacific region,
with DPT3 coverage below 70%, are the Lao
People’s Democratic Republic (57%), which has
raised its coverage notably from 18% in 1990,
and the Pacific island countries of Papua New
Guinea (64%), Palau (49%) and Vanuatu (68%),
all of which have registered declining coverage
rates.

The proportion of children 1 year old or younger
immunized against measles is a standard
MDG-4 monitoring indicator. Measles is highly
contagious; and in order to prevent devastating
outbreaks, immunization coverage rates must be
consistently high. The global measles elimination
goal is that countries must achieve 95% coverage
of measles vaccine. In Asia and the Pacific, the
percentage of children 1 or under who were
vaccinated against measles in 2009 was 83%,
which is much below the recommended 95%.
The subregions of South and South-West Asia
(at 76%), the Pacific (80%) and South-East Asia
(88%) are still more than five percentage points
below the 95% recommendation. As observed
in DPT3 data, India has a high percentage of
unvaccinated children; only 71% of children 1
or younger are vaccinated against measles.

Functional national childhood immunization
programmes are considered an egalitarian publichealth
service provided to all classes of people in
developing countries. Immunization rates are
therefore a good indicator of the extent of
inequalities that prevail in any given area/country.
In terms of economic status, the population in
the poorest quintile in Asian and Pacific countries
generally had much lower rates of measles
immunization coverage than those in the richest.
Specifically in India, the immunization rate of the
poorest quintile was 40% (the lowest in the Asia-
Pacific) while the immunization rate of the
richest quintile was 85% (a level similar to many
other Asia-Pacific countries).

Causes of Under-five Mortality in Asia and the Pacific

In Asia and the Pacific, the major causes of child mortality are largely preventable; yet, in 2008, over 3 million
infants and an additional 0.6 million children under 5 continued to die each year1. The Child Health Epidemiology
Research Group of WHO and UNICEF have comprehensively reviewed the causes of child mortality worldwide
and produced evidence-based estimates related to time and cause of child mortality for each country for 2008.
Based on this research, two out of every five child deaths (38.4%) occur during the neonatal period, from birth to
28 days of life. Those deaths were the result, in descending order, of preterm birth complications (14.4%), birth
asphyxia (11.4%), neonatal sepsis (6.9%), congenital abnormalities (5.0%), and neonatal tetanus (0.7%). Neonatal
deaths are closely linked to maternal deaths that in turn are related to standards of antenatal care and whether
skilled health providers attend childbirth. Maternal and child health programmes need to be directed at both the
pregnant mother and the newborn in order to improve these indices.

Pneumonia and diarrhoea cause 19.5% and 13.1%, respectively, of under-five mortality after the neonatal period
(including neonatal deaths due to those diseases), representing a huge unfinished agenda. Together they account
for 1.26 million or about one third of all child deaths in the Asia-Pacific region. These leading killers of children
are largely preventable with simple and effective interventions such as antibiotics for pneumonia and oral rehydration
solutions for diarrhoea. Yet public health systems in many countries struggle to deliver timely interventions to a large proportion of their child populations. Access, especially for the most deprived, is a result of both supplyand
demand-side barriers that need to be overcome.

Childhood diseases such as measles, pertussis and meningitis that are preventable by existing vaccines account for
another 6.8% of the under-five deaths in Asia and the Pacific – despite routine childhood immunization programmes
that operate in all countries. An additional proportion (13.5%) of under-five deaths is caused by a variety of infectious
diseases, likely reflecting poor socio-economic status and harmful environmental conditions, compounded by lack
of health service access. Two such diseases, malaria and HIV, cause 0.8% of child deaths – in contrast to the situation
in Africa, where they cause 20% of child deaths. Finally, childhood injuries as a result of drowning and other accidents
are an important preventable cause of under-five deaths comprising 4.3% of the U5MR burden.
Although under-nutrition, which includes stunting, severe wasting, and deficiencies of vitamin A and zinc, is not
presented as a direct cause of death in these statistics, it has been found to be an underlying cause of under-five
deaths. Inadequate breastfeeding is often part of the under-nutrition problem.

Under-five deaths by cause, Asia and the Pacific, 2008

Notes: All countries in the Asia-Pacific region for which data are published were grouped together for this analysis; the countries without data are the Pacific island
countries or areas of American Samoa, French Polynesia, Guam, New Caledonia and Northern Mariana Islands. The “other infections” category includes some
deaths due to preterm birth complications, birth asphyxia, and other prenatal causes.

1 The data in this text box is from: Black, Robert E., and others (2010). Global, regional, and national causes of child mortality in 2008: a systematic
analysis. Lancet, 375: 1969-87.